Abstract
BackgroundDeep vein thrombosis (DVT) is common in critically ill patients with Coronavirus disease 2019 (COVID-19) and may cause fatal pulmonary embolism (PE) prior to diagnosis due to subtle clinical symptoms. The aim of this study was to explore the feasibility of bedside screening for DVT in critically ill COVID-19 patients performed by physicians with limited experience of venous ultrasound. We further aimed to compare inflammation, coagulation and organ dysfunction in patients with and without venous thromboembolism (VTE).MethodsThis observational study included patients with COVID-19 admitted to the intensive care unit (ICU) of a tertiary hospital in Sweden and screened for DVT with proximal compression ultrasound of the lower extremities between April and July 2020. Screening was performed by ICU residents having received a short online education and one hands-on-session. Pathological screening ultrasound was confirmed by formal ultrasound whereas patients with negative screening underwent formal ultrasound on clinical suspicion. Clinical data, laboratory findings and follow-up were extracted from medical records.ResultsOf 90 eligible patients, 56 were screened by seven ICU residents with no (n = 5) or limited (n = 2) previous experience of DVT ultrasound who performed a median of 4 (IQR 2–19) examinations. Four (7.1%) patients had pathological screening ultrasound of which three (5.6%) were confirmed by formal ultrasound. None of the 52 patients with negative screening ultrasound were diagnosed with DVT during follow-up. Six patients were diagnosed with PE of which four prior to negative screening and two following negative and positive screening respectively. Patients with VTE (n = 8) had higher median peak D-dimer (24.0 (IQR 14.2–50.5) vs. 2.8 (IQR 1.7–7.2) mg/L, p = 0.004), mean peak C-reactive protein (363 (SD 80) vs. 285 (SD 108) mg/L, p = 0.033) and median peak plasma creatinine (288 (IQR 131–328) vs. 94 (IQR 78–131) μmol/L, p = 0.009) compared to patients without VTE (n = 48). Five patients (63%) with VTE received continuous renal replacement therapy compared to six patients (13%) without VTE (p = 0.005).ConclusionICU residents with no or limited experience could detect DVT with ultrasound in critically ill COVID-19 patients following a short education. VTE was associated with kidney dysfunction and features of hyperinflammation and hypercoagulation.Trial registrationClinicalTrials ID: NCT04316884. Registered 20 March 2020.
Highlights
Hypercoagulation and associated deep vein thrombosis (DVT) is a common and severe consequence of the inflammatory response in critically ill patients with Coronavirus disease 2019 (COVID-19) and has led to implementation of COVID-19 specific thromboprophylaxis regimens [1,2,3,4,5,6,7]
venous thromboembolism (VTE) was associated with kidney dysfunction and features of hyperinflammation and hypercoagulation
All patients admitted to the intensive care units (ICU) with COVID-19 diagnosis confirmed by positive SARS-CoV-2 reverse transcription polymerase chain reaction tests on nasoor oropharyngeal swabs were eligible for lower extremity Deep vein thrombosis (DVT) screening with proximal compression ultrasound (2-CUS or extended compression ultrasound (ECUS)) as soon as possible after ICU admission and included in the present analysis if they were ≥ 18 years old and had respiratory failure (PaO2/ FiO2 ratio ≤ 40 kPa (300 mmHg)) [29]
Summary
Hypercoagulation and associated deep vein thrombosis (DVT) is a common and severe consequence of the inflammatory response in critically ill patients with Coronavirus disease 2019 (COVID-19) and has led to implementation of COVID-19 specific thromboprophylaxis regimens [1,2,3,4,5,6,7]. As an alternative to CDUS, two-region compression ultrasound (2-CUS) of the common femoral and popliteal veins only, is accurate for diagnosing DVT in non-COVID-19 patients and can be performed by emergency and critical care physicians [12,13,14]. Deep vein thrombosis (DVT) is common in critically ill patients with Coronavirus disease 2019 (COVID19) and may cause fatal pulmonary embolism (PE) prior to diagnosis due to subtle clinical symptoms. The aim of this study was to explore the feasibility of bedside screening for DVT in critically ill COVID-19 patients performed by physicians with limited experience of venous ultrasound. We further aimed to compare inflammation, coagulation and organ dysfunction in patients with and without venous thromboembolism (VTE)
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